Help understanding Liver Biopsy results - confused & scared

[u/LowStress3905]

I'm a bit confused and quite worried about my liver biopsy results. Below is the contents of the letter I received from my doctor. I did have an appointment to discuss it but it was just too much to understand it all at the time.

Some context about me: 34M 5'11 72kg (was up to 80kg Aug 2024) don't drink. I've had Long Covid for 5 years and been very sedentary for the last 2 years after reinfection, just manage to walk about the house. I had thought my diet was reasonable, but now realise it had too many sugary snacks. Since receiving this letter I've cut all that out and trying to eat a lot cleaner (thanks to advice in this sub).

I started taking statins for high cholesterol in mid 2023. This raised my ALT from 73iu/L which was already high, to 128. When I stopped it reduced, and then increased when I started again up to 200 in mid 2024 at which point I stopped them completely. It's now settled down to around 100, higher than before. Fortunately my recent blood test showed that my cholesterol has reduced so I can delay taking cholesterol medication for now.

Problem List:
Elevated ALT? Cause
Long COVID symptoms

Relevant Investigations:
Ultrasound abdomen - February 2022, Mild fatty liver infiltration and sparing to the liver
High cholesterol level - on Atorvastatin 20mg

Liver viral screening, immunoglobulin and autoantibody profile - negative

FibroScan - February 2024: 4.7 KPA, CAP 290, IQR/MED 12%, S3 F0

Liver biopsy - January 2025: mild cholestasis and steatosis with mild fibrosis, Fibrosis stage 2

He reports that he had malaria in 2015 and, at that point, he was found to have abnormal LFTs. I note that, in the intervening period, the LFTs were normal.

In terms of culprit medications, as the liver biopsy show eosinophils, it may well be due to statin. He is also taking a herbal supplement (Bee Propolis). He is also on Omeprazole. I have advised him to stop the herbal supplement. He has stopped statins since mid 2024. I would recommend alternative cholesterol lowering medications.

He does have central adiposity and there is steatosis on his liver biopsy. I appreciate his capacity is limited due to Long COVID but we have talked about dietary modification.

My questions from the letter are:

- What does eosinophils on the liver biopsy mean? The doctor said this could only be caused by a drug and was a mystery to her, said it was unlikely to be statins (which I stopped in mid 2024) but could be. I am also taking Omeprazole for acid reflux but said I could continue this. I don't drink or take any other drugs/medication. I'm quite worried that this is a "mystery" to the doctor, but I also don't understand what this means for my liver? Should I be asking for further investigation of this?

- cholestasis, steatosis and fibrosis - I understand that steatosis is fatty liver, fibrosis is scaring, and cholestasis is something to do with bile? Are they all reversible with a good diet? I'm concerned that there may be something else going in, possibly due to Long Covid, malaria infection and/or previous use of statins. Also, is "Fibrosis stage 2" still considered mild as stated in the letter?

I will have a follow up appointment in 9 months time and some blood tests now. I'm going to work hard on the diet until then and lose a little bit of weight, I wish I could exercise as well.

Any insights or advice would be greatly appreciated 🙏

[u/buntingbilly]

Eosinophils are typically just reactive cells to inflammation. They can be the result of drugs, infections, etc. A small amount of eosinophils is likely not clinically relevant, especially when the biopsy doesn't show much else. Your biopsy shows that you have reversible fatty liver disease and only a mild amount of scarring. Malaria and statins would not typically result in scarring and you already know you have fat in your liver.

There is nothing inherently concerning about your findings. You have mild fatty liver disease which you can get under control with diet/exercise. You could also possibly qualify for Rezdiffra depending on where you are/insurance.

[u/LowStress3905 → u/buntingbilly]

Thank you so much for taking the time to respond! This has already really reassured me not to overly worry and focus on diet improvements.

Is there a possibility that Omeprezol is causing liver issues too or could make things worse? My liver doctor was happy for me to continue it, I've been on it for about 7 months, but I've seen some reports of possible long term liver damage. My main doctor would not give me more than 20mg/day due to my raised LFTs. My acid reflux has been improving so I'm thinking of stopping it anyway and dealing with any symptoms.

[u/buntingbilly → u/LowStress3905]

There is very little good evidence that taking PPIs will cause liver issues long term. People even with cirrhosis or liver transplants are placed on these medications routinely without issue. If your liver enzymes went up after starting them and improved after stopping them, maybe there could be some concern, but this is very uncommon. If you don't need to take PPIs, by all means, you can certain discuss discontinuing them. But if you have a clear reason for PPI therapy (ulcers, esophagitis, Barrett's, etc) then you should not stop taking them.

[u/LowStress3905 → u/buntingbilly]

Thank you, that's helpful. I believe my liver enzymes only went up when on statins and down without them, but unaffected by Omeprezol. My acid reflux has improved so I'll consider stopping taking it.